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A Tale of Two Medicines (or, Getting off the Doctor-Go-Round!)
All Aboard the Doctor-Go-Round
The following story illustrates an all-too-common scenario in today’s health care system: the failure of specialized medicine to recognize conditions underlying the typical chronic disorder ...
* * * * *
On a fine, autumn morning in a large American metropolis, primary care physician “Doctor X” received a new patient, Karen, who complained of fatigue, dizziness, chest pains, constipation, bouts of confusion, and depression. The gradual onset of these symptoms had begun only a few weeks after her recovering from mononucleosis. While her new symptoms differed somewhat from those of mono, the possibility of relapse greatly concerned her.
The doctor performed the cursory examination allowed by her insurance company, and found tender glands, but otherwise normal “vitals.” He also drew blood and urine samples to rule out relapsing mono and other diseases such as diabetes, liver disease, and AIDS. Yet concerned by her “chest pains” and other reported symptoms, he decided a referral to his cardiologist-friend “Doctor C” was justified.
The following week, Karen, still feeling poorly, saw “doctor C” in his office. He listened to her heart and chatted about her symptoms while an assistant readied her EKG. Then he left the room to analyze the EKGs while she dressed. He soon returned with an upbeat flourish: “well Karen, you can stop worrying about the big one! I wish I had your ticker!” Happy to see a weak smile brighten her face, he promised to pass the news to Doctor X, and sent her home.
Karen’s smile didn’t last long, and she rang Doctor X herself the next day. “It’s nice to know my ticker’s ok, but frankly I still feel terrible ... and I’m missing tons of work!” He asked her to try and relax. Having ruled out her heart, he suspected her dizziness may hold the answer. His golfing buddy was the noted neurologist, “Doctor N,” and would certainly see her as soon as possible. “By the way, here’s more good news: your mono tests came back negative!
“Mono was never this much fun thought Karen as she dragged herself out of bed the following week to see doctor N. There, she received a battery of neurological tests, after which doctor N scheduled an MRI and more blood tests. He concluded the exam by telling her “your responses are a bit sluggish Karen, but otherwise well within normal. We’ll have your scans and other results soon. Meantime I’m prescribing something to help you with depression. Get plenty of rest and we’ll see if your energy improves.”
A few days later, Karen was on the phone, ranting weakly at Doctor X: “Get some rest! he says! Rest is all I do ... all I can do! These chest pains are spreading to my arms, and now I’m getting diarrhea!” Doctor X’s light-hearted response: (“well, at least you’re not constipated”) was met by grim silence. “I’m sorry Karen”, he sighed, “I can imagine how frustrated you must feel ... but we’re getting very close. We must be ... which reminds me! I play racquetball with a top GI guy - Doctor G - and I’ve asked him to fit you in right away.”
Doctor G fit Karen in as promised, obtained stool, blood, stool and urine samples, and called her the following week to tell her it all looked good, but that he’d need a colonoscopy to rule out diverticulitis, Crohn’s and other serious problems. Karen agreed, and the following day picked up her prescription: a up large jug of “citrus flavored” laxative preparation. On the appointed night before the surgery, she downed the salty-tasting liquid - then remained stationed within close proximity to the toilet far into the night. She arrived at the GI clinic the following morning short on sleep and jittery. Fortunately, a nurse soon slipped an i.v. into her arm. When it was all over she was too woozy to care about the results. She only wanted her ride to take her home to her waiting bed.
Later that evening Doctor X called to check in and give her the good news: no turnips growing in your tummy! “Doctor G told me your colon looks great! Well, other than it seems somewhat spastic ... Actually Karen, you appear to have a condition we call “Irritable Bowel Syndrome” ... and it’s something you may have to live with for the time being. But the good news is that it’s nothing life-threatening, Karen. It could have been so much worse!
“That’s wonderful doc” she answered in a weakly scarcastic tone. “My butt is a little spastic ... but no one ever died of a spastic butt, right? Meanwhile I still have a few other issues doctor, like ... I can’t think straight? I can’t stay awake - or asleep? I hurt all over, and feel like crying 10 times a day? If I were my husband I’d ... oh, please doctor, please keep trying! Don’t give up on me!” Dr. patted her shoulder. “I’m not giving up on you, Karen, and don’t you give up on you either. Believe it or not, we’re very close. We must be, after ruling out so many possibilities. Now I want you to call ‘Doctor R’ on Monday. He?s a fantastic rheumatologist ... incredibly busy - but also happens to be my old med-school room-mate - so be sure to mention my name!”
Doctor R, while fondly reminiscing his doctor x days, gave Karen a major workup. Afterward he set Karen’s mind to rest regarding arthritis, autoimmune disease, osteoarthritis and even early osteoporosis: “Karen, I cannot find a thing wrong with you - physically. Normally this should be good news ... however, as you are obviously suffering I actually wish I’d found a problem! At least I could have treated it. What I can do however is give you something for the pain - when it becomes severe. And Karen, please use these with discretion ... they can be habit forming. ” On the way home she wept in frustration - retreated to her bed and stayed there the next twenty hours, ignoring the phone, her mind repeating the age old question: why me?.
Sometime on Friday she finally answered the phone, to hear Doctor x’s concerned voice say: “I spoke with Doctor R Karen ... and I know ... you’re frustrated, and this is getting old ... but remember what they say about the darkest hour?”
“That’s a good one doc! I’ll have to try it on my employers… oh, I’m sorry!” she broke down.
“Have them call me Karen. I’ll help you any way I can,” he continued, “but please come to my office tommorrow. I ... I have a theory ...
Doctor x’s words intrigued Karen. What could this new theory possibly be? Were any stones left unturned, she wondered, trying to ignore the big “C” word lurking in the darker regions of her mind. That wasn’t the theory, however ... which became painfully obvious when, the following day, he passed her an expensively engraved, white linen business card bearing the words: “Bertram T. Bankhead, General Psychiatry.”
The doctor spoke first: “You know Karen, I’m not doubting for one minute that everything you feel is real - to you. However the mind can be unbelievably powerful - enough to actually alter your physiology - make you feel sick ... be sick!”
Finding her voice, Karen stood her ground: “Now that is crazy, doctor ... I don’t want to be sick! My family needs me, and ... its not like I hate my job ... I love my work! Why would my brain want me to be sick?
I can’t answer that one Karen, but maybe Ed can. He and I ski together, and he’s one of—
“Oh yes, I know!” she cut him short “He’s tops in his field, right?
“Karen please!” The doctor’s eyes pleaded, just promise me you’ll think it over - fair enough?
“Fair enough.” She dropped the card into her purse and rose, tiredly. Without looking up she bid the doctor goodbye and went home, thinking only of ... sleep!
* * * * *
Karen thought it over, and decided against seeing Dr. Bankhead. Some inner voice told her not to cross that bridge, because it could only lead to self-doubt and confusion. That was the day Karen began listening to her own intuition again. It told her that what was wrong was real enough - but somehow extraordinary, or unusual to most physicians. Somehow, she knew she would have to find the right doctor - and treatment - to get better. That was the day she began taking control of her life, and her health.
So concluded Karen’s odessey through medical maze of US health care “leaf doctors” - chasing a diagnosis that proved as elusive as the proverbial Fountain of Youth.
The following joke has been making the rounds - Question: “What is the definition of a specialist?” Answer: “Someone that know more and more about less and less. The ultimate specialist therefore, knows everything there is to know ... about nothing!
Most jokes are contain a grain of truth. Likewise, the specialists Karen visited each “saw” her through the “tunnel-vision” of their particular specialty. Beyond that which they’d been trained to recognize lay only a kind of void - a “blind spot.” The Cardiologist examined each symptom in relation to her heart and vascular system. The Gastroenterologist related them only to her gut. The Neurologist saw only brain and CNS ... the Rheumatologist - bone and joint tissue.
Specialists are trained to diagnose largely through exclusion; “ruling out” possibilities until only the most likely remain. This approach will not work for a “Karen”, because while her symptoms may be cataloged under their specialization - the correct disorder would not. Hence she would most likely be misdiagnosed or else simply deemed “healthy” and cleared of their specialization’s diseases. Meantime, the riddle of her true disorder remains unsolved.
Clearly, a new approach has been needed, and a new kind of physician. A new discipline drawing upon a comprehensive body of clinical knowledge and experience could be effectively deployed only by a new kind of “multi-specialist” - trained to recognize chronic disorders within the context of familiar yet puzzling recurrent symptoms. Fortunately that very discipline and its practitioners have emerged: known as Functional MDs.
Functional medicine is nothing less than fascinating, however before delving into it, let us return briefly to Karen’s story, which has also taken an interesting turn!
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Added: 2007 09 24
